Table 2

Number and percentage of various types of medication administration errors identified across all wards/hospitals

Type of medication administration errorNo of errors (percentage of all errors)Examples
Incorrect preparation errors89 (20.7)
  • Not shaking suspension bottle before withdrawing medication

  • Not preparing intravenous medications aseptically

Incorrect rate of intravenous administrations85 (19.8)
  • Metronidazole (5 ml=25 mg) administered intravenously through a peripheral line over 10 min (30 ml/h) instead of the recommended 30 min

Incorrect time80 (18.7)
  • Metronidazole 260 mg administered intravenously three times a day; one dose was given at 17:45 instead of the prescribed time 14:00

Left drug by patient’s bedside without checking drug administration43 (10.0)
  • Nurse prepared the following without labelling them and left them by the patient’s bedside for the mother, who was asleep, to administer; when the mother woke up, she found by her child: seven capsules of 500 mg sodium benzoate, and two 20 ml syringes of water to dissolve the content of the capsules before administration, and to flush the nasogastric tube before and after administration

    Seventeen millilitres in syringe of 250 mg/ml sodium phenyl butyrate (which looked very similar to the 20 ml syringes of water)

    7 ml in a syringe of L-arginine

    10 ml in syringe of domperidone

    The mother dissolved the seven capsules in a syringe of liquid and administered it, but it was unclear whether water or sodium phenyl butyrate had been used; the mother then asked the nurse for help; the pharmacist intervened, and the medications were not given for 1 day to prevent overdose due to the uncertainty over whether patient had the medications

Incorrect dose40 (9.3)
  • Tenfold error involving heparin (patient given 5 ml instead of prescribed 0.5 ml)

Incorrect administration technique23 (5.4)
  • Not flushing nasogastric tube or intravenous access before administrations to check they were not blocked

Omission error22 (5.1)
  • Omitting drugs; this was either because the drug was not available on ward or because the nurse did not realise the drug was due for the patient

Unordered drug error16 (3.7)
  • Giving cefuroxime to the patient when there was no prescription for it

Omission of nurses’ signature following administration12 (2.8)
  • Nurses did not sign the drug charts following drug administrations

Administration of extra dose5 (1.2)
  • Giving an extra dose of flucloxacillin; this was mostly due to the nurses who gave the previous doses not signing the drug chart to indicate that dose already given

Incorrect drug3 (0.7)
  • Calcium chloride (SandoCal) was prepared instead of prescribed drug potassium chloride (Sando-K)

Miscellaneous medication administration errors11 (2.6)
  • Giving the drug via the incorrect route (giving paracetamol rectally where the oral route prescribed)

  • Incorrect preparation errors means that the drug was prepared incorrectly, not according to the hospital drug preparation policy or the manufacturer’s instructions.